To Kegel or Not to Kegel? That is the Question!

Every few years, the Kegel exercises come under attack. Practicing Kegels is often cited as the cause of difficulty during the pushing stage of birth, due to bearing down against contracted rather than relaxed pelvic floor muscles. This increases resistance to fetal movement, potentially damaging soft tissue, as well as stressing maternal cardiac reserve and the fetal heart. So, a call goes out to stop doing Kegels. But, Kegels were invented for a reason, and contracting the pelvic floor during birth is not it.

So, to kegel or not to kegel? Two things help us understand how to answer the question of whether or not – and when – to do Kegels. One is history (ever a useful tool) and the other is identifying the anatomy and physiological functions of the female pelvic floor.

1) History

Hands and knees is mechanically efficient for mom's body to "cradle" the fetus.

Hands and knees is mechanically efficient for mom’s body to “cradle” the fetus.

 

First thing, a quick peek at evolution. The pelvic floor did not originally support the contents of the abdomen. Starting out as 4-legged creatures, our pelvic floor originally served more as the back door.

Sacrum & Coccyx at top. Pubis at bottom. Evolution position.

Sacrum & Coccyx at top. Pubis at bottom. Evolution position.

Thus, the opening and closing of outlets were primary functions, and support of abdominal contents was largely a job for the Transverse Abdominals.

We could rock into an upright posture (squatting or sitting on our “sitsbones”), allowing gravity to assist in downward emptying of abdominal contents. When we relax our skeletal muscles, the involuntary muscles and neuro-motor emptying pathways proceed unfettered.

Squatting

Squatting

Once we discovered we could stand on our feet and still reach much of the fruit in the trees, a fast transition to upright (in evolutionary terms) placed strain on movement and support in the pelvis, spine and hip joints. Reviewing all the details involved in the ensuing adaptations is another story for another day. Suffice it to say, supporting the abdominal contents was not included in the original design of the pelvic “floor.”

Fast forward to the end of the 19th Century when birth began moving into a clinical setting and women were routinely placed on their back for labor and birth.

Pubis at top. Sacrum and coccyx at bottom. Supine position.

Pubis at top. Sacrum and coccyx at bottom. Supine position.

Yes, this slowed down the process and made it more painful. Thus, the next steps emerge in the early 20th Century: “Twilight Sleep” and increased forceps birth.

For a good understanding of this era, I recommend the following 1916 article:

  • Haultain FWN and Swift BH. The Morphine-Hyoscine method of painless childbirth or so-called “Twilight Sleep,” British Medical Journal, 1916 Oct 14;2(2911):513-5. Full text here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2354830/pdf/brmedj07070-0003.pdf

  • The reader can also learn more about Twilight Sleep and its adaptations in the U.S. by entering “twilight sleep childbirth” into the PubMed search field.

Next: Urinary incontinence! Or, the reason Kegels were invented.

So, what was the product of placing women on their backs, putting them into a semi-conscious state, amnesia of events, and sometimes dragging the baby out of the vagina with forceps? Likely, increasing incidence of pelvic floor dysfunction. However, additional factors also influence maternal pelvic floor outcomes, including the Valsalva maneuver during pushing, and instrumental birth. Who invented “pushing” anyway? Male doctors.

  • For more on such matters, I recommend the reader examine Sheila Kitzinger’s work. She is a renowned British anthropologist who studied, wrote and spoke on global birth customs throughout her life.

Pushing, or bearing down, occurs naturally during coughing, sneezing, emesis, forced exhalation (as when a tennis player grunts while hitting a ball), urination, defecation and – when occurring without analgesia – parturition (birth). Identifying the “best” way to push remains illusive. What is the goal? Speed, damage control, fetal outcome? The Cochrane Library concludes only that maternal preferences and medical imperatives should guide the method of pushing.

  • Lemos A et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2015 Oct 9;10:CD009124. doi:10.1002/14651858.CD009124.pub2.

And, what about organ prolapse? How does that figure in here? Is weakness in the pelvic floor muscles a cause? It is becoming more clear that, even in the absence of trauma, genetic factors play a significant role in the occurrence and severity of pelvic floor dysfunction. There is great variability in how connective tissues respond to stress and stretching. A good recent account of one possible gene avenue is this article:

  • He K, Niu G, Gao J, Liu JX, Qu H. MicroRNA-92 expression may be associated with reduced estrogen receptor β1 mRNA levels in cervical portion of uterosacral ligaments in women with pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 2016 Mar;198:94-9. doi: 10.1016/j.ejogrb.2016.01.007. Epub 2016 Jan 11.

In the early-mid 20th Century, much less was understood about how genetics, physical training, postural sway and practice protocols might affect these matters. In 1948, Dr. Arnold Kegel, an American gynecologist, published on a non-surgical method of toning the pelvic floor in order to help women control incontinence following childbirth. By exercising the pubococcygeus muscles (PC muscles or sphincters) of the pelvic floor, he found that women could reduce their likelihood of experiencing bladder problems after pregnancy and birth. Here are the two publications that give rise to calling these exercises “Kegels.”

  • Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948 Aug;56(2):238-48.
  • Kegel AH. The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure. Ann West Med Surg. 1948 May;2(5):213-6.

Keep these factors in mind: The experiments leading to publication included measurement of the strength of contraction of these muscles. Several devices (balls, cones and devices that read muscle strength) were developed to provide tactile aid in contracting and releasing the PC or sphincter muscles, and continue to be used today by physiotherapists. These actions are aimed at squeezing the detrusor (or urinary flow mechanism) to prevent incontinence with weak or relaxed sphincters.

What about the issue of organ prolapse? How does that tie in? Over time, the term “Kegel” has also come to refer to tightening the levator muscles (the sling-like muscles that lift the pelvic floor). This action is the opposite of what happens when bearing down. Which nicely brings us to the second topic:

2) Anatomy and Functions of the Female Pelvic Floor

There are three rings of muscles and four muscle actions that govern the opening and closing of the bony structures and soft tissue of the pelvic floor. The overall bony shape of the pelvic floor is similar to a baseball diamond, as seen in the first graphic.

Pelvic outlets, lithotomy position.

Pelvic outlets, lithotomy position.

 

The three rings are – from outside to in:

  1. Gluteals, transverse perineals and ischiocavernous that create two triangles of the pyramidal bony structure and create a rigid fence when contracted or a mobile structure when released. The deep rotators, including piriformis, and the pyramidalis also function to close the pelvic outlet.
  2. Levator and diaphragm muscle that lift and close the pelvic floor and/or support the contents of the abdomen by contracting when the woman is vertical.
  3. Sphincter muscles that squeeze and release the three orifices: urethra, vagina and anus, closing and opening these outlets.

The four muscle actions are:

  1. Contraction – tightening the muscle as in strength training. Can be done to shorten muscle (concentric) or as muscle extends (eccentric). Muscles can shorten approximately half their resting or relaxed length. Contracting muscle against resistance increases cardiovasculature and improves delivery of nutrients and oxygen, as well as improving innervation and awareness of motion.
  2. Release/Relaxation – letting go of contraction, allowing muscle to rest, relax or be stretched.
  3. Stretching – muscles can be lengthened approximately a third of their resting length by applying leverage to the bony structures the muscle controls. Stretching is also affected by genetic factors regarding elasticity of the connective tissue within and attaching to muscle and bone.
  4. Bulging or Distending – Some muscles can extend beyond their stretching range by pressure from the diaphragm, often termed “bearing down.” Both the Transverse Abdominals (TA) and pelvic floor muscles do this during parturition (efforts to expel the baby). The TA tighten in a distending position to assist in the emptying of the abdominal contents and the pelvic floor extends beyond the bony structure defined by the sit bones (ischial tubersoities) on either side of the vagina. To get a sense of how this occurs, I recommend two things: first, cough hard enough that you can sense the action of TA and pelvic floor; second, next time you take a poop, sense how your body is working. It is the same for parturition, although the target is the vagina rather than the anus and the voluntary assisting effort needed is much more intense. Two practices help prevent damage to the pelvic floor. One is following the urge to push and the other is to “labor down” when their is no urge, when the mother needs to rest a bit during pushing. Avoiding, as much as possible, the Valsalva maneuver (holding the breath while pushing) reduces strain on maternal cardiac reserve and the fetal heart.

An excellent way to get a sense of how the pelvic floor functions in birth is to view the 1974 Brazilian film, Birth in the Squatting Position. Here is the link:

https://www.youtube.com/watch?v=ZHHHcIZEi9U&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DZHHHcIZEi9U&has_verified=1

So, do we do Kegels? Yes, but we also release/relax, stretch and learn the coordination of bulging/distending these muscles. After birth and as we age, we also do them as a method of recovery and because we are upright animals who have to support the contents of the abdomen. Learning to sit in an anatomically neutral position in a chair and many other healthy postural habits – not to mention understanding our genetic factors regarding elasticity – will also help us maintain a healthy pelvic floor. But these ideas are another story for another day.

 

About Dancing

“When a normal, healthy child is born, usually in the father’s compound, the women perform the nkwa to rejoice. Then…they sing and dance their way to the compounds of the mother’s kin to inform them of the joyous event through the dance-play, gathering additional dancers as it moves from compound to compound. In this nkwa, in which only married women who have given birth perform, the dancers highlight procreative body parts, birth exercises and child care gestures.” – page 164, Hanna JL, To Dance is Human: a theory of non-verbal communication, 1979. Rev. ed. 1987.

From its inception in 1979, Dancing Thru Pregnancy® has been inspired by this passage from Judith Lynne Hanna’s amazing text, in which she describes how the Ubakala of Nigeria “announce” the birth of a child. The dance serves a dual purpose – it tells of the birth, but it also teaches the uninitiated how pregnancy and birth occur. For the dancers it also serves as a catharsis.

As a professional dancer, I long ago recognized the transformative power of dance to make experiences accessible.Molly and Miri Through Hanna’s writing we see how dance is itself one of the earliest and most profound ways in which common human experiences are taught and learned. Contemporary culture often removes this type of learning from our environment. Employing dance to help women approach birth has always struck me as an obvious first choice in preparing women for the physical, emotional, identity-forming and joyful process of birth.

In the intervening years, science and technology have reinforced our understanding of how this non-verbal learning happens. A most excellent discussion of mirror neurons appears in Acharya and Shukla’s article, Mirror Neurons: Enigma of the metaphysical modular brain, J Nat Sci Biol Med. 2012 Jul-Dec; 3(2): 118–124. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510904/. Mirror neurons are key to how empathy and understanding of experience are produced when people view movement and gesture. The mere perception of an action sets off a low level firing of the neural pathway that executes the actions we are seeing. The authors provide a thorough grounding in the history of how we have come to recognize that mirror neurons exist and how they work.

There are more arenas in which dance also shines as a preparation. Appropriately choreographed, dance enables excellent physical fitness and includes all the elements of physical activity that research demonstrates are effective for optimal health in pregnancy and coping with the rigors of birth. From the perspective of exercise physiology, labor is an ultra-distance endurance event, followed by a strength test (birth), a long physical recovery period and 18 years or more of sleep deprivation. And, further, such a preparation aids the mother in achieving a physiologic birth as described in Buckley’s “Hormonal Physiology of Childbearing: Evidence and implications for women, babies, and maternity care.” This recent groundbreaking article describes how labor, birth and breastfeeding are promoted through hormonal actions, as well as why some technological advances in childbirth are working against these processes.

DTP at YH 12:13Achieving cardiovascular endurance (aerobic fitness) is essential. There are so many benefits of aerobic fitness that a full recitation and hundreds of citations will not fit in a blog. Our teacher training aerobic component takes several days, even for experienced fitness pros. But, to summarize: cardiovascular fitness improves implantation, enhances nutrient and oxygen delivery, reduces the incidence or severity of some pregnancy disorders, reduces the risk of fetal distress, reduces stress on maternal cardiac reserve while pushing, reduces the risk of cesarean, hastens recovery, helps maintain a healthy weight, alleviates anxiety, builds body-image confidence (Cochrane) and enhances long term maternal and fetal health. The two forms of cardio or aerobic activity most often cited for effectiveness are running and aerobic dancing.

Two other elements of dance that are useful for pregnant, birthing and parenting moms are strength and flexibility. There are Elongemany movement actions derived from numerous dance forms that promote both power and elasticity in the muscles, connective tissue and skeletal structure. Some effective positions, movements and skills are shared with other disciplines: Traditional childbirth preparation, weight training, gymnastics, physical therapy, yoga, t’ai chi, pilates, boot camp, plyometrics, proprioceptor neuromuscular facilitation (PNF) techniques, Feldenkrais, Alexander, somatic therapies, posture training, etc.

This letter I received recently from a (not pregnant) ballet student willing to share her experience is a clear reminder of how a well-designed dance class accomplishes enhancement of strength and flexibility, along with confidence about working with one’s body:

“Hi Ann,

I just wanted to let you know that I lifted weights at the gym last night… It had been at least 6 months since I had lifted weights at all, and so I figured I’d need to start at a relatively low weight and I’d be really sore the next day regardless. I was very surprised to find that I could easily lift the maximum weight I’ve ever lifted, which was the weight I used to lift at a time when I was lifting weights routinely several times a week. Every muscle group was strong. And today I am not sore at all. This is all to say that I am shocked at how much strength I’ve gained from ballet. I had no idea that just lifting my limbs against gravity could be so effective.

Thank you so much for having a class for beginner adults, and for your patience with all of us! I’m 42 years old at this point, and started ballet because I had noticed my core strength, flexibility and balance starting to really decline…I am so thrilled with the results from ballet even though I have such a long way to go!!! Plus it’s really fun. How I wish I would have discovered ballet in my 20s or 30s, since I didn’t learn it as a child!

Glenda G. Callender, MD FACS

An additional arena in which dance shines is in building mind-body skills. Dancing relies on centering – aligning with gravity to produce the greatest efficiency for movement (balance) along with breathing as a component of movement. Centering also reduces the load on the nervous system and allows the brain to modulate into the parasympathetic nervous system state, also known as the relaxation response (autogenic training, hypnosis, meditation, progressive relaxation), the zone (athletes’ term), mindfulness (big in research presently), the trophotropic response (the scientific term) or the alpha state (the current fad term). Dancers sometimes refer to this as tuning in to the unconscious. The actual coordination of motions, such as pushing, is primarily unconscious. The conscious piece is keeping a clear image of the goal, while allowing the body to work. This is the skill that allows the birthing mother to follow her body’s urges, flowing with the labor rather than trying to control what is going on. It gives her access to the cathartic nature of birth as a dance.

Centering 2:08Align

Breathe

Focus on the breath

Sense the movement within

Then, allow the body to dance…

A part of the dance experience I truly enjoy is a phenomenon known as muscle bonding. When a group does vigorous physical activity together – dancing together, a sports team, a drill team – a special kind of bond forms. Part of the euphoria is this muscle bonding experience.  Those of us whose interest lies in understanding the mechanics of such things have a pretty good idea how this works – some of which is laid out in this blog and the reading links. But, that is not the wonder of it. The wdancing_overview from backonder of it is what the Ubakala women experience moving together to announce the birth of a child.

When I am dancing with my pregnant ladies and we are in the grove with our modified hip hop routine, we are smiling at each other and feeling completely alive. We are breathing hard and working hard, but we are strong. My hope is always that when she senses that labor and birth are starting, a mom-to-be can get in that groove with the baby and support person. Birth as a dance.

No blog on pregnancy or birth is complete without a caveat. Every pregnancy and birth is unique. Sometimes things go wrong. But, mostly they go right! And, moms can optimize the experience. One of the greatest dangers to pregnancy and birth is sedentary behavior. Regular, vigorous, strength-inducing, flexibility gaining, mindfulness, relaxation muscle bonding fun is available. Check our U.S. and International Find-a-Class listing. If there is nothing near you, start something!

Dispelling Myths on Pregnancy Exercise

At regular intervals, it becomes necessary to dispel two persistent myths that are often perpetuated by well-meaning care providers. Both of them were debunked long ago, in research literature that is readily available and about which I have written a great deal, including in my chapters on Women and Exercise (editions 3 & 4) and Health Promotion in Varney’s Midwifery (edition 5), in posts on the DTP website, on my Twitter feed (@anncowlin), on DTP’s Facebook page and in a textbook.

DTP_mover1_pregnantThe more common myth is that pregnant women should never let their pulse get over 140 beats per minute. But, more on that one at another time. That was an ACOG guess in 1985 that long ago (1994) was rescinded.

The other is that pregnant women should never begin a new exercise regimen, but only modify (i.e., reduce) what they are already doing. What brings me to write this blog after a blog break (to respond to our expanding pre/postnatal fitness teacher training program) is that this evening I was told the latter myth was promoted by a CNM at a recent nearby conference. A childbirth education colleague alerted me to this occurrence and also to the happy response by an unknown person in the audience, who chose to differ with the midwife, citing Dancing Thru Pregnancy® as her example!! Thank you to this responder.

Let me address – yet again – the issue of whether it is safe for pregnant women to begin an exercise regimen after they become pregnant. The caveat I offer at the outset is that doing so should be under the supervision of a knowledgeable certified pre/postnatal fitness specialist. Within the profession, the resolution of this question is generally agreed to be the Cochrane Review conducted in 2002, which found that aerobic fitness can be improved or maintained in pregnancy. Improvement requires increasing the level of aerobic challenge. More recently, researchers concluded “….pregnant women benefit from regular physical activity the same way as non pregnant subjects…” and that “…[t]he adoption or continuation of a sedentary lifestyle during pregnancy may contribute to the development of certain disorders such as hypertension, maternal and childhood obesity, gestational diabetes, dyspnoea, and pre-eclampsia.” (Melzer et al. Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes. Sports Med. 2010 Jun 1;40(6):493-507. 

Put another way, the female is not put together to be sedentary in pregnancy. It is only in recent decades that this is an option. Until the mid 20th Century, activities of daily living required physical fitness, and obesity was rare, along with sedentary behavior. In the last few decades, those who are knowledgeable about the interactions of pregnancy and exercise, and who have the experience of teaching movement to this population, have come to understand how to present activities that improve the factors that improve maternal and fetal outcomes.

Those who are extremely well-versed in the field all agree that cardiovascular (aerobic) fitness during the 6 – 12 month pre-pregnancy period may be the greatest pregnancy enhancement a woman can have. Why? Because endothelial function is greatly enhanced, oxidative stress is reduced, and vascularity is increased by aerobic fitness, and these capacities underly healthy implantation and placental development (see Research Updates 2001-2005, Winter 2005 and Winter 2004 and Update on Immune Function). Barring that, beginning early in pregnancy is helpful because placental development is still underway. Barring that, mild to moderate aerobic activity introduced by 25-30 weeks will produce cardiovascular enhancement by the time of labor. My caveat goes here, too.

All conditions mediated by inflammation are a problem in pregnancy. Physical fitness is a major preventive strategy for inflammation, and pregnancy does not stand in the way.

 

 

Blood Pressure in Pregnancy

I was recently asked some questions regarding blood pressure during pregnancy by my colleagues at Physiquality. In preparing material, I wrote this blog, which includes very basic clinical information and explanations about this topic.

What is the normal range for blood pressure for pregnant women? What readings would fall under high blood pressure?

Blood Pressure (BP) in pregnancy is a complex topic.

First, we need to know: What are the classifications of BP?

The chart below is from the evidence-based 2014 Guidelines of the American Heart Association and the National Heart, Blood and Lung Institute of the NIH. The first number is Systolic BP or during the heart beat. The second number is Diastolic BP or between beats. These numbers are relevant for women of childbearing age.

  • Normal                        <120 mm Hg and <80 mm Hg
  • Pre-hypertensive          120-139 or 80-89
  • High BP Stage 1            140-159 or 90-95
  • High BP Stage 2            ≥ 160 or ≥ 10

Why does low BP (hypotension) occur in a healthy pregnancy?

A healthy pregnant woman with normal BP and no cardiovascular or immune system complications, will have pregnancy BP lower than her non-pregnant BP due to increased progesterone relaxing her vasculature. To create the placental and uterine blood flow, blood volume (V) expands rapidly increasing by around 40%, but stroke volume increases less, so beats per minute (pulse) may increase, systolic BP may drop 5 mm Hg and diastolic may drop 10-15 mm Hg. If V is not adequate with this relaxed vasculature, BP may drop even lower. To help maintain normal BP, women are encouraged to drink sufficient water (about 8 glasses/day) and eat enough protein (about 20-25% of daily intake) to produce a blood volume that will sustain an adequate BP. Other more severe conditions – often genetic – may also be relevant, such as postural orthostatic tachycardia syndrome.

Other causes of hypotension include lying still on the back with legs extended for long periods of time after the first trimester. The weight of the uterus impinges on the vena cava returning blood to the heart, thus reducing BP and blood flow to the uterus and placenta. Also, standing for long periods of time with a minimum of motion, as happens with teachers, cashiers, line workers and nurses in the second half of pregnancy when increasing relaxin and elastin cause further softening of vasculature. This results in difficulty returning blood from the lower limbs and reducing blood flow to the uterus and placenta.

What are hypertensive disorders of pregnancy?

According to the National High Blood Pressure Education Working Group on High Blood Pressure in Pregnancy, hypertensive disorders of pregnancy are presently classified into four categories:

  • Chronic hypertension (pre-existing)
  • Preeclampsia-eclampsia
  • Preeclampsia superimposed on chronic hypertension
  • Gestational hypertension

[The Society of Obstetricians and Gynecologists of Canada categorize these disorders as pre-existing or gestational, with the addition of preeclampsia to either category.]

Chronic hypertension is BP >140/90 prior to pregnancy or before 20 weeks. New onset of high BP after 20 weeks may indicate preeclampsia (PE), which requires further consideration. PE involves other symptoms and organs. It occurs in about 5% of all pregnancies, 10% of first pregnancies and 20-25% of women with a history of chronic hypertension. It is a serious disorder and major cause of adverse maternal and fetal outcomes, including strokes, seizures and restricted fetal growth and development.

The underlying pathogenesis of preeclampsia-ecclampsia is not yet fully understood, but is a fundamental dysfunction of the placenta leading to endothelial dysfunction and vasospasm. Possible causes include pre-existing endothelial dysfunction, metabolic dysfunction, auto-immune responses and infection. It is likely that the placenta is affected very early on, during implantation, trophoblast invasion of the uterus and opening of the spiral arteries to form the blood pool on the maternal side of the placental circulation.

Gestational hypertension is the onset of BP >140/90 after 20 weeks without other features of preeclampsia. About 1/3 of these women develop preeclampsia. Gestational hypertension is highly associated with hypertensive disorders later in life. Diabetes can also be a factor associated with hypertension.

Whenever a woman has elevated BP in pregnancy, she needs to be evaluated and have a follow up course of observation and treatment. At its most severe, a hypertensive disorder can affect all the body’s organs and systems, and can be fatal.

What can pregnant women do (diet, exercise, healthy habits) to keep their blood pressure within a normal range?

Some risk factors for hypotension or hypertensive disorders of pregnancy are inherited, others are a consequence of behavior, and many are a combination.

What can a woman do before pregnancy?

Because the events that pre-dispose a woman to hypertensive disorders may occur before she knows she is pregnant, some efforts at prevention may be helpful in the six months to a year prior to pregnancy. Preparing for the implantation period by maintaining optimal health and fitness is likely the most helpful behavior. Cardiovascular or aerobic fitness, which prevents or reduces the severity of endothelial dysfunction is highly valuable. An adequate daily nutrient intake along with sufficient water, and maintaining a BMI <25 are important factors. Women with elevated blood pressure should discuss with their care provider the balance of sodium and potassium intake, along with the total allowable amounts.

Avoiding infections or illness around the time of conception may be a factor. Hypertensive disorders are mediated by inflammation. Unfortunately, another factor may be the maternal immune response to the fetal DNA. This may also be dependent on combined maternal/paternal immune system responses.

What can a woman do once she is pregnant?

Once a woman is pregnant, maintaining optimal health and fitness continue to be important. Even if there are pre-disposing factors for disorders, she may be able to reduce the severity by staying fit, well nourished and well rested. A balanced and colorful diet, along with avoidance of alcohol, drugs and unsafe behaviors are critical.

The ability to achieve the Relaxation Response, meditation, deep breathing and hypnosis are valuable for acute BP reduction. Each of these skills is mediated by the parasympathetic nervous system response (or alpha brain rhythm) and mitigates the effects of stress on a temporary basis. Cardiovascular or aerobic fitness is effective for long-term BP reduction, as well as cardiovascular health.

Resting on the left side maximizes circulation and – if possible – finding 15 or 20 minutes to rest this way during the day is beneficial, especially if a woman’s work involves standing for long periods of time. Avoiding lying on the back or standing for long periods of time is advisable. Finding a community of support for having a healthy pregnancy can be a great asset, as well.

Safe Pregnancy, Safe Labor, Safe Motherhood

The challenges to safe motherhood vary depending where in the world you live. In some areas the challenge may be to get adequate nutrition or clean water; in other areas, it may be to prevent infection; and in still other locations it may be trying to avoid pregnancy before your body is ready or getting access to prenatal care. In the U.S., it may mean avoiding being sedentary and making poor food choices, or having to deal with the high technology environment of medical birth that can sabotage the innate physiological process of labor and birth.

Birth begins the bonding or unique love between mother and child.

The biology of birth is a complex series of cause-effect processes…baby’s brain releases chemical signals to the mother and the placenta begins to manifest the maternal immune system’s rejection of the fetus.

To help the ball get rolling, relaxation (the trophotropic response) helps promote the release of oxytocin. With the help of gravity, the head presses on the cervix, amplifying the uterine contractions. After an ultra-distance aerobic endurance test, the cervix opens enough to let the baby move into the vagina and the mother’s discomfort moves from sharp cramping into the bony structure as she transitions to the strength test of pushing. She transitions. Relaxation modulates into an ergotropic – adrenal – response to gather her power.

Pushing is an interesting term…more masculine, I think, than the one I prefer:  Releasing. Releasing or letting go of the baby. It’s a catharsis. In this portion of the labor another set of important processes help the baby clear its lungs of amniotic fluid, stimulate its adrenal system and challenge its immune system, as the contractions drive the baby downward. The mother’s deep transverse abdominal muscles – if strong enough – squeeze the uterus like a tube of tooth paste, to aid this expulsion. In the meantime, the labor is helping set up the mother to fall in love and produce milk. When the baby emerges and moves onto the mother’s chest, s/he smells and tastes the mother, recognizing her mother’s flavor and setting up the potential for bonding.

Any way you slice it, there are two parts to safe motherhood. One is a safe pregnancy…healthy nutrition, physical fitness, safe water, infection prevention, support and a safe environment. The other is a safe labor. In a safe labor, there is both an environment that promotes the natural process of labor and the means necessary for medical assistance when needed. Women die at an alarming rate from pregnancy or birth-related problems. Despite some progress made in recent years, women continue to die every minute as a result of being pregnant or giving birth.

What keeps us from having a better record on motherhood is often lack of care in the developing world and too much intervention in the U.S.. They are two sides of a coin. Mothers’ experience and health needs are not on equal footing with other cultural values. In places where basic prenatal care or family planning are low priorities, at-risk women are vulnerable to the physical stresses of pregnancy and birth. In the U.S., machine-measured data is paramount, even if it produces high rates of false positives, unnecessary interventions or counterproductive procedures. We are learning that obesity and sedentary lifestyles have detrimental effects, but fewer pregnant women than their non-pregnant counterparts exercise.

Despite the money spent to support the technological model of pregnancy and birth in the U.S., there are parts of the world – especially Scandinavia, Northern Europe and parts of the Mediterranean and Middle East (Greece, the United Arab Emirates, Israel, Italy and Croatia) – with lower rates of maternal deaths. In fact, in the U.S., maternal deaths are on the rise.

It’s a tricky business. Clearly Western medicine has a lot to offer the developing world when there are medical concerns. On the other hand, importing the U.S. model could create more problems than it solves. Instead, the micro-solutions now being developed in many locations will be observed and evidence collected by organizations such as the White Ribbon Alliance and UNICEF.

There is an effective international midwives model adopted by JHPIEGO, the Johns Hopkins NGO working toward improved birthing outcomes. It assesses the local power structure, social connections, potential for trained birth assistants, and location of available transportation to create a network so that locals will know when a labor is in trouble and who can get the woman to the nearest hospital.

In the U.S., there are in-hospital birth centers that allow low-risk mothers the opportunity to labor and birth in a setting designed to encourage the innate processes. Women are beginning to vote with their feet…staying home for birth. Women are going abroad to give birth. At the same time, women are coming to this country to give birth, believing it is safer than where they are. There are several ways these scenes could play out.

But, I’ll wager, improving outcomes will involve compromise:  Watchfulness and support in most births, plus better ways to assess danger and provide technology. No matter where you live in the world, the solution may be essentially the same.

High Birth Weight: The New Bad Outcome

While public awareness of low birth weight and premature infants is becoming – at long last – interesting to the mainstream culture and media, another phenomenon is beginning to shake the professional birthing world:  high birth weight. Because it is occurring in a more affluent element of society, it is alarming. This tells us that you cannot buy your way out of pregnancy risks that are created by a sedentary, toxic food life-style.

Here is the dilemma:

Normal weight and some overweight women who eat too much in pregnancy tend to have babies who are, basically, already obese at birth. Therefore, these infants already have metabolic and cardiovascular dysfunction. Babies born over 8 lbs. 14 oz. are at increased risk for Type 2 Diabetes and heart disease.

Interestingly, the Institute of Medicine  recently issued new guidelines on pregnancy weight gain. After nearly 20 years of adhering to the “normal” weight gain being 25 to 35 pounds, the Institute recognized that prenatal BMI plays a role in how much weight gain is necessary for a healthy pregnancy.

The evidence that underlies this change demonstrates that gains greater than 22 pounds – for all classifications of prenatal BMI – is the demarkation point for increased health problems.  More information on this is available at:  New IOM Guidelines.

We have known for a while now that obesity in pregnancy puts mother and infant at risk for a number of problems from cardiovascular, metabolic and immune disorders to prematurity, low birth weight, increased need for cesarean birth and slow recovery. Add another one:  Obese newborns with increased risk for heart and metabolism problems.

Reference on weight gain and high birth weight:

Ludwig DS, Currie J. The association between pregnancy weight gain and birthweight: a within-family comparison. Lancet. 2010 Sep 18;376(9745):984-90. Epub 2010 Aug 4.

A good reference for issues surrounding obese pregnancy:

Leddy MA et al. The Impact of Maternal Obesity on Maternal and Fetal Health. Rev Obstet Gynecol 2008;1(4):170-178.

Breastfeeding Research Demonstrates More Baby Protections

We have long known that vaginal birth and breastfeeding are key factors in the development of a healthy immune system in infants. Passing through the vagina exposes the baby to an array of bacteria that help stimulate its unchallenged immune system. Breast-fed babies receive anti-bodies, proteins and other molecules that protect it from infection and teach the immune system to defend the infant.

Breastfeeding is key for long-term health.

Recent research at UC Davis has shown that a strain of the bifido bacteria – acquired from the mother – thrives on complex sugars (largely lactose) that were previously thought to be indigestible. The bacterium coats the lining of the immature digestive tract and protects it from noxious bacteria.

This combination of interactions affects the composition of bacteria in the infant gut as it matures. Another example of how evolution has “invented” the perfect nutrition for infants, this research contributes to the notion that evolution has selected for many genes that serve normal birth and breastfeeding by protecting the newborn. Intervening with the normal progression of birth and breastfeeding – while occasionally necessary – interrupts these beneficial adaptations and contributes to allergies and autoimmune disorders.

You can read more about this research in the NYTimes Science section. Our Twitter feed (on the Right side of this blog) will take you to the link for this article. It’s worth the trip!!